3 Session 2 goals Paris classification system reviewDye and optical staining methodsRole in detectionRole in classification; Kudo & SanoUnderstand settings they are useUtilize to differentiate neoplastic potentialBy the end of this session, participants will be understand the three major classification systems (Paris, Kudo, Sano), understand the settings in which they are used, understand the utility each has in detection and classification and show proficiency in their application

4 The Paris ClassificationSnarepolypectomyEMR en blocOr piecemealEMR en bloc,ESD, or surgeryAdenomaHigh gradeadenomaCarcinomaHistology ResectionI-pI-sII-a-b-cParis class if probably the most recognized and used. It refers to the morphology of a lesion.IIImixed

13 Kudo pit patterns Developed for use in chromoendoscopyIndigo carmine remains in depressions (pits)The violet dyes actually stain the mucosaResults not replicated with NBI in absence of dye staining.

18 Kudo pit patterns Non-neoplastic Neoplastic Type II: HyperplasticType III-L: AdenomaNon-neoplastic lesions can be distinquished from neoplastic lesions based on the shape, size and regularity of the crypt.Compare the Kudo II Hyperplastic lesion shown on the left with the Type III-L adenoma on the right. Notice that the crypts become elongated and larger in the adenoma compared to the hyperlastic lesion.Tubular or round, elongated, large pits.Large, star like (or onion)crypts.Regular pattern

20 Kudo pit patterns Non-neoplastic Neoplastic Type II: HyperplasticType III-s: High grade lesionNon-neoplastic lesions can be distinquished from neoplastic lesions based on the shape, size and regularity of the crypt.Compare the Kudo II Hyperplastic lesion shown on the left with the Type III-L adenoma on the right. Notice that the crypts become elongated and larger in the adenoma compared to the hyperlastic lesion.Compact, smaller than normal pits.Large, star like (or onion)crypts.Regular pattern

21 Kudo pit patterns Adenoma Advanced adenoma Type III-L:Type V: High grade lesionNeoplastic lesions can be further distinguished as adenomatous vs. cancerous based on the organization of the MC structure.Here the question doesn’t become whether the Meshed capillaries are present but rather the organization of the capillary pattern around the glandsPits look branched or gyrus likeTubular, elongated, large pits.

22 Kudo pit patterns Adenoma Advanced adenoma Type III-L:Type III-s: High grade lesionNeoplastic lesions can be further distinguished as adenomatous vs. cancerous based on the organization of the MC structure.Here the question doesn’t become whether the Meshed capillaries are present but rather the organization of the capillary pattern around the glandsPits look branched or gyrus likeTubular, elongated, large pits.

38 Sano capillary patternsCP I:Normal mucosaHyperplastic lesionsCP II:Adenomatous lesionsFirst we’ll look at hyperplastic vs. adenomatous lesions.When using Sano to make this distinction, the first question is whether you can see the capillary patterns. If they are not visible or only faintly visible then it’s either normal mucosa or a hyperplastic lesion.If the meshed vessels are clearly visible then what is the pattern?With current resolution, a honeycomb pattern may be faintly seen in large hyperplastic lesions. However the meshed capillaries in adenomas are very clearly seen and are elongated and large in comparison.Meshed capillaryvessels （‐）Meshed capillaryvessels （+）

41 Sano capillary patternsCP II:Adenomatous lesionsCP III:Cancerous lesionsNeoplastic lesions can be further distinguished as adenomatous vs. cancerous based on the organization of the MC structure.Here the question doesn’t become whether the Meshed capillaries are present but rather the organization of the capillary pattern around the glandsNo honeycomb pattern.Irregularity of size, complex branching, disruption, or irregular winding.Round, oval, honeycomb likepattern. May be elongated andlarge diameter.

45 Sano capillary patternsCP III A:Cancerous lesionsCP III B:Cancerous lesionsNeoplastic lesions can be further distinguished as adenomatous vs. cancerous based on the organization of the MC structure.Here the question doesn’t become whether the Meshed capillaries are present but rather the organization of the capillary pattern around the glandsMeshed capillary vessels characterized by:blind ending, branching and curtailed irregularlyLack of uniformityHigh density ofcapillary vesselsNearly avascular or loosemicro capillary vessels